Patient Passed In Hospital Pet's Name: *Owner's Full Name: First and Last: *(If you will be getting ashes returned please fill out the Last name you would like on the pet's urn.)Phone Number:Please read carefully and check mark all that apply:* I, the undersigned, do hereby certify that I am the owner (duly authorized agent for the owner) of the animal described above. I do hereby give Northeast Veterinary Clinic complete authority to perform the requested services on my deceased animal in whatever manner I have requested. I would like to do the following with my pet's remains: Individual Cremation Communal Cremation (Ashes will not be returned) Clay Paw (Requires cremation services) Taking home remains (No cremation services being done) If you are requesting more than 1 clay paw please enter quantity below:Each clay paw is an additional chargeElectronic Signature by entering your FULL NAME *I certify that this form has been reviewed by me. I have read it and understood all the aspects of this form. I understand and agree to its contents.Today's Date: *
